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Sadlonova M, Beach SR, Funk MC, Rosen JH, Ramirez Gamero AF, Karlson RA, Huffman JC, Celano CM. Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms. J Intensive Care Med 2023:8850666231222470. [PMID: 38130132 DOI: 10.1177/08850666231222470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margo C Funk
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Jordan H Rosen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Andres F Ramirez Gamero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rebecca A Karlson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Balcioglu YH, Gokcay H, Kirlioglu Balcioglu SS, Solmaz M. Increased Dispersion of Ventricular Repolarization as an Arrhythmic Risk Marker in Drug-free Patients With Major Depressive Disorder: A Preliminary Comparative Study. J Psychiatr Pract 2023; 29:282-290. [PMID: 37449826 DOI: 10.1097/pra.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Drug-free patients with major depressive disorder (MDD) are understudied in terms of increased risk for arrhythmias. In this study, we compared changes in corrected QT interval (QTc), QTc dispersion (QTcd), Tpeak-Tend (Tp-e), Tp-e/QT ratio, corrected JT interval (JTc), and JTc dispersion (JTcd), which are considered to be among the risk factors for the emergence of ventricular arrhythmias in patients with MDD. METHODS The study involved 50 patients with MDD who had been free of psychotropic medications for at least 1 month and 52 age-matched and sex-matched healthy controls. Illness-related characteristics, including duration of illness and Beck Depression Inventory scores, were recorded. Electrocardiography recordings made under a standardized procedure were performed for all participants, and arrhythmia risk markers were calculated from the electrocardiograms. RESULTS The patient group had significantly higher QTcd, JTc, and JTcd values compared with the controls. Among electrocardiogram markers, only Tp-e/QTc was significantly and inversely correlated with the duration of illness, while none of the markers was associated with Beck Depression Inventory scores. CONCLUSIONS Alterations in electrocardiogram-derived markers of ventricular arrhythmia, which can be obtained easily and inexpensively, can be evaluated for the prediction and prevention of severe cardiac conditions in patients with MDD and considered in selecting the safest antidepressant options available.
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Wang Z, Li L, Huang S, Wang X, Liu S, Li X, Kong W, Ni X, Zhang M, Huang S, Tan Y, Wen Y, Shang D. Joint population pharmacokinetic modeling of venlafaxine and O-desmethyl venlafaxine in healthy volunteers and patients to evaluate the impact of morbidity and concomitant medication. Front Pharmacol 2022; 13:978202. [PMID: 36569310 PMCID: PMC9772442 DOI: 10.3389/fphar.2022.978202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction: Venlafaxine (VEN) is a widely used dual selective serotonin/noradrenaline reuptake inhibitor indicated for depression and anxiety. It undergoes first-pass metabolism to its active metabolite, O-desmethyl venlafaxine (ODV). The aim of the present study was to develop a joint population pharmacokinetic (PPK) model to characterize their pharmacokinetic characters simultaneously. Methods: Plasma concentrations with demographic and clinical data were derived from a bioequivalence study in 24 healthy subjects and a naturalistic TDM setting containing 127 psychiatric patients. A parent-metabolite PPK modeling was performed with NONMEM software using a non-linear mixed effect modeling approach. Goodness of fit plots and normalized prediction distribution error method were used for model validation. Results and conclusion: Concentrations of VEN and ODV were well described with a one-compartment model incorporating first-pass metabolism. The first-pass metabolism was modeled as a first-order conversion. The morbid state and concomitant amisulpride were identified as two significant covariates affecting the clearance of VEN and ODV, which may account for some of the variations in exposure. This model may contribute to the precision medication in clinical practice and may inspire other drugs with pre-system metabolism.
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Affiliation(s)
- Zhanzhang Wang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Lu Li
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Shanqing Huang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,School of Pharmacy, Guangzhou Medical University, Guangzhou, China
| | - Xipei Wang
- Medical Research Center, Guangdong Province People’s Hospital, Guangdong Academy of Medical Sciences, Cardiovascular Institute, Guangzhou, China
| | - Shujing Liu
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,School of Pharmacy, Guangzhou Medical University, Guangzhou, China
| | - Xiaolin Li
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,School of Pharmacy, Guangzhou Medical University, Guangzhou, China
| | - Wan Kong
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,School of Pharmacy, Guangzhou Medical University, Guangzhou, China
| | - Xiaojia Ni
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Ming Zhang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Shanshan Huang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yaqian Tan
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China
| | - Yuguan Wen
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China,*Correspondence: Dewei Shang, ; Yuguan Wen,
| | - Dewei Shang
- Department of Pharmacy, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China,Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China,*Correspondence: Dewei Shang, ; Yuguan Wen,
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Gutlapalli SD, Lavu VK, Mohamed RA, Huang R, Potla S, Bhalla S, Al Qabandi Y, Nandula SA, Boddepalli CS, Hamid P. The Risk of Fatal Arrhythmias in Post-Myocardial Infarction Depression in Association With Venlafaxine. Cureus 2022; 14:e29107. [PMID: 36258960 PMCID: PMC9572810 DOI: 10.7759/cureus.29107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/13/2022] [Indexed: 11/18/2022] Open
Abstract
Venlafaxine is a second line anti-depressant and the most commonly used in the treatment of selective serotonin reuptake inhibitor nonresponders in major depression; due to its effects on the noradrenergic and serotonergic systems as a serotonin and norepinephrine reuptake inhibitor, there has been considerable apprehension regarding its use in patients with cardiovascular diseases, particularly post-myocardial infarction depression, some of the feared adverse effects include QT prolongation, arrhythmias including torsades de pointes and sudden cardiac death. We tried to resolve the facts regarding the risks associated with venlafaxine use in cardiac patients. We have reviewed all the relevant information up to May 2022 regarding the risks of venlafaxine use in cardiovascular disease, particularly with a focus on post-myocardial infarction depression, and gathered around 350 articles in our research and narrowed it down to 49 articles. The database used was PubMed and the keywords used were venlafaxine, arrhythmia, major depression, post-myocardial infarction, and ventricular tachycardia. We carefully screened all relevant articles and found articles supporting and refuting the effects of venlafaxine in increasing cardiovascular morbidity and mortality. We have concluded that there is a significant variability due to confounding factors affecting individual cases. Overall there is no increased arrhythmia risk in comparison with other anti-depressants except in high-risk cases such as with pre-existing cardiovascular disease, certain genotypes, and other co-morbidities. Any patient with a high risk of arrhythmias due to any etiology should receive a screening electrocardiogram before venlafaxine prescription for baseline QT interval and periodically while on therapy to check for changes. We encourage further research, including randomized clinical trials and post-marketing surveillance regarding the use of venlafaxine in high-risk cases such as patients with multiple co-morbidities, elderly patients, or patients with certain genotypes.
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Wang H, Wu Y, Zou Q, Yang W, Xu Z, Dong H, Zhu Z, Wang D, Wang T, Hu N, Zhang D. A biosensing system using a multiparameter nonlinear dynamic analysis of cardiomyocyte beating for drug-induced arrhythmia recognition. MICROSYSTEMS & NANOENGINEERING 2022; 8:49. [PMID: 35547605 PMCID: PMC9081091 DOI: 10.1038/s41378-022-00383-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/14/2022] [Accepted: 04/07/2022] [Indexed: 06/15/2023]
Abstract
Cardiovascular disease is the number one cause of death in humans. Therefore, cardiotoxicity is one of the most important adverse effects assessed by arrhythmia recognition in drug development. Recently, cell-based techniques developed for arrhythmia recognition primarily employ linear methods such as time-domain analysis that detect and compare individual waveforms and thus fall short in some applications that require automated and efficient arrhythmia recognition from large datasets. We carried out the first report to develop a biosensing system that integrated impedance measurement and multiparameter nonlinear dynamic algorithm (MNDA) analysis for drug-induced arrhythmia recognition and classification. The biosensing system cultured cardiomyocytes as physiologically relevant models, used interdigitated electrodes to detect the mechanical beating of the cardiomyocytes, and employed MNDA analysis to recognize drug-induced arrhythmia from the cardiomyocyte beating recording. The best performing MNDA parameter, approximate entropy, enabled the system to recognize the appearance of sertindole- and norepinephrine-induced arrhythmia in the recording. The MNDA reconstruction in phase space enabled the system to classify the different arrhythmias and quantify the severity of arrhythmia. This new biosensing system utilizing MNDA provides a promising and alternative method for drug-induced arrhythmia recognition and classification in cardiological and pharmaceutical applications.
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Affiliation(s)
- Hao Wang
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-sen University, Guangzhou, 510006 China
| | - Yue Wu
- Research Center for Intelligent Sensing Systems, Zhejiang Lab, Hangzhou, 311121 China
| | - Quchao Zou
- ZJU-Hangzhou Global Scientific and Technological Innovation Center, Department of Chemistry, The Second Affiliated Hospital Zhejiang University School of Medicine, Department of Clinical Medical Engineering, Zhejiang University, Hangzhou, 310058 China
| | - Wenjian Yang
- Research Center for Intelligent Sensing Systems, Zhejiang Lab, Hangzhou, 311121 China
| | - Zhongyuan Xu
- Research Center for Intelligent Sensing Systems, Zhejiang Lab, Hangzhou, 311121 China
| | - Hao Dong
- Research Center for Intelligent Sensing Systems, Zhejiang Lab, Hangzhou, 311121 China
| | - Zhijing Zhu
- Key Laboratory of Novel Target and Drug Study for Neural Repair of Zhejiang Province, School of Medicine, School of Computer & Computing Science, Zhejiang University City College, Hangzhou, 310015 China
- School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, 310058 China
| | - Depeng Wang
- College of Energy and Power Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, 210016 China
| | - Tianxing Wang
- E-LinkCare Meditech Co., Ltd., Hangzhou, 310011 China
| | - Ning Hu
- State Key Laboratory of Optoelectronic Materials and Technologies, Guangdong Province Key Laboratory of Display Material and Technology, School of Electronics and Information Technology, Sun Yat-sen University, Guangzhou, 510006 China
- ZJU-Hangzhou Global Scientific and Technological Innovation Center, Department of Chemistry, The Second Affiliated Hospital Zhejiang University School of Medicine, Department of Clinical Medical Engineering, Zhejiang University, Hangzhou, 310058 China
- State Key Laboratory of Transducer Technology, Chinese Academy of Sciences, Shanghai, 200050 China
| | - Diming Zhang
- Research Center for Intelligent Sensing Systems, Zhejiang Lab, Hangzhou, 311121 China
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Antipsychotic-Related Fatal Poisoning, England and Wales, 1993-2019: The Impact of Second-Generation Antipsychotics. J Clin Psychopharmacol 2021; 41:650-657. [PMID: 34668874 DOI: 10.1097/jcp.0000000000001479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Deaths from antipsychotic (AP) poisoning have increased in England and Wales despite restriction of the use of thioridazine in 2000. METHODS We analyzed data from the Office for National Statistics drug-related death database, England and Wales, 1993-2019, to investigate fatal AP poisoning. RESULTS There were 2286 deaths (62% male patients). Annual numbers of intentional AP-related fatal poisonings (suicides) were relatively stable (1993, 35; 2019, 44; median, 44; range, 30-60). Intentional overdose deaths involving clozapine (96 male, 25 female) increased from 1 in 1994 to 5 in 2003 and have since remained relatively constant (median, 6; range, 3-10 per annum). Unintentional second-generation AP-related fatal poisonings have increased steadily since 1998, featuring in 828 (74%) of all unintentional, AP-related fatal poisonings in the period studied (2019, 89%). There were 181 unintentional clozapine-related deaths, (107 [59%] alone without other drugs ± alcohol) as compared with 291 quetiapine-related deaths (86 [30%] alone without other drugs ± alcohol) and 314 unintentional olanzapine-related deaths (77 [25%] alone without other drugs ± alcohol). Some 75% of all unintentional clozapine- and olanzapine-related deaths were of male patients (78% and 73%, respectively) as compared with 58% of unintentional quetiapine-related fatal poisonings. Clozapine now features prominently in intentional and in unintentional AP-related fatal poisoning in England and Wales. Deaths of male patients predominate in both categories. There were also 77 and 86 deaths attributed to unintentional poisoning with olanzapine and with quetiapine, respectively, in the absence of other drugs. CONCLUSIONS More effort is needed to prevent unintentional deaths not only from clozapine but also from olanzapine and quetiapine.
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